Writing Mysteries in the Age of COVID-19

As always, I’m curious on how to plot a murder mystery and have been peeking at how death investigations have changed.

Since COVID-19, mystery writers attempting to hide a murder have a different landscape to deal with. If a person is COVID-19 positive, even if they wouldn’t die from the disease - this is far more possible with the Omicron variant - a murder via poison at home would be easier to conceal.

Recently, our jurisdiction changed the rules stating, “Autopsies will no longer be performed on someone who is suspected to have died from COVID-19 unless there is another factor of great significance, such as a homicide.”

So, without evidence of blunt force trauma or anything obviously untoward, a murder via poison in a COVID-19 positive person can be more easily hidden.

Is this true in other jurisdictions?

“During the pandemic, many sick people have stayed at home and died there rather than seeking help at hospitals overwhelmed with coronavirus patients.

“In April in New York City, for example, a reported 200 residents died at home each day, compared with 20 such deaths before the pandemic…If family or friends say the person had symptoms consistent with COVID-19, the coroner's office will typically do a nasal swab to test for the virus, he says. If the test is positive and the office can determine the cause of death without an autopsy, one will generally not be performed.”

A review of the literature shows, “The literature is dominated by appeals for more autopsies to be performed…The main reason for the great reluctance worldwide to perform autopsies seems to be concerns about infectivity emanating from deceased persons.”

In the United States, there’s the added problem of cost, availability of specialists and the vast number COVID-19 deaths.

“Hospitals are not required to provide autopsy services, and in those that do perform them, the procedure’s costs are not directly covered by most private insurance or by Medicare…Added into the mix: The number of experts who can actually perform autopsies is critically low. Estimates suggest the U.S. has only a few hundred forensic pathologists but could use several thousand — and less than one in 100 graduating medical school students enters the profession each year.”

Add to this the fact that there are almost 860k COVID-19 deaths to date, the volume of detailed death investigations, let alone autopsies, of those who die out of hospital would overwhelm the system. So they are not done.

In hospital deaths are also not autopsied but with COVID-19 restrictions on visitors it would be hard to write a plausible mystery involving a murder in hospital.

So if autopsies aren’t done for most COVID-19 deaths, is toxicology conducted?

“How are forensic toxicology tests done? At the time of the autopsy, collection of blood, urine, and tissue samples is done in preparation for the toxicology tests, says Barbarajean Magnani, PhD, MD, chairwoman of the Toxicology Resource committee for the College of American Pathologists.”

So, given the concerns about infection from COVID-19 would collection of samples occur? I have not found evidence to suggest it is done.

While this certainly makes for intriguing options for writing mysteries, it’s a huge loss to science. Fulsome and numerous autopsies are the one crucial way to obtain information about a disease. For scientific purposes, more rather than fewer autopsies should be conducted. However, the limitations of time, personnel, well-ventilated facilities and PPE have limited autopsies and we have lost a great deal of data. Because of this, there’s been a pushback from many to perform more autopsies.

“The results from the analyzed studies show that autopsies are essential in the COVID-19 pandemic. They enable a more differentiated assessment of mortality. More important than the determination of the cause of death, however, is the fact that only the autopsy (including histological and virological examinations) opens up the possibility of investigating the spread of the virus in the body, the involvement of various organ systems, but also the late effects of the disease…

There are few valid reasons not to perform autopsies in COVID-19 deceased if the technical equipment meets certain minimum standards. It is easy to protect oneself against infection during the autopsy. Both clinical and forensic pathologists – preferably in cooperation – play an important role in gaining knowledge about the new disease as a basis for therapeutic measures and global pandemic control.”

I do wonder how mysteries written in the age of COVID-19 will be different because of the new landscape of death investigations.

Dr. Josh Trebach and his Tox Murder Mysteries

I usually interview people and write articles, but not today.

First, let me introduce you to Dr. Josh Trebach, an emergency physician and toxicology fellow at NYC. You can follow him @jtrebach on twitter and following him is a treat for anyone interested in the lovely combination of medicine and mystery.

Second, let me explain why I didn’t interview Dr. Trebach. He writes murder mystery threads. They are so perfectly written, that I asked him for permission to put them, largely unedited, in an article.

So, here’s how he introduces his mysteries: Buckle up - it’s tox murder mystery thread.

Without further ado, here are two of his mysteries. 

Tox murder mystery #1.

A 45 year old man is found dead in the orthopedic room of an emergency department. He has no signs of trauma and no past medical history.

What do you think happened?

Clues

1. The man was hired by the hospital to clean drain pipes blocked by plaster washed down the sink by silly residents. (Stop washing your plaster down the sink! I see you!! STOP DOING IT! It's nasty and gross)
2. The material used to make the splints was Plaster of Paris. This product is still used today.
3. The man was using sulfuric acid to clean the drain and dissolve the clogged up Plaster of Paris. I'm a toxicology fellow, not a drain declogging expert, what do you want from me? I don't know why they used that.
4. What happens to Plaster of Paris when its gunked up in the pipes?  It gets chewed up by bacteria. Under anaerobic conditions, the bacteria can make a nasty, thick (thicc?) calcium sulfide sludge.
5. Sulfuric acid + Calcium Sulfide = ??? UGHHHHH chemistry.

Yet, the answer is in here. These two combine in the following chemical reaction, giving us our answer.

  CaS + H₂SO₄ → CaSO₄ + H₂S  

The culprit: Hydrogen Sulfide gas was formed by the chemical reaction above and it caused the man to die pretty quickly. Perhaps the only thing abnormal on the patient's skin exam was his silver wedding ring that had tarnished after reacting with the gas.

Hydrogen sulfide is a colorless gas that classically smells like rotten eggs . It gets inhaled into the body and interferes with oxidative phosphorylation and causes cellular hypoxia. What does this translate into? Rapid unconsciousness and cardiopulmonary arrest.

Hydrogen sulfide is scary. People will die in groups because whenever someone (not wearing PPE) goes to rescue the victim, they become exposed to the gas and then pass out/die… and the cycle continues.In fact, at ~1000ppm, breathing will STOP after just 1-2 breaths.

Treatment: Moving the victim to fresh air and giving oxygen, in addition to good supportive care and respiratory/ventilatory support, is key. Antidotes such as sodium nitrite work by inducing methemoglobinemia which scavenges the hydrogen sulfide.

Tox murder mystery #2.

A 33 year old woman is found dead in a bank vault. She has no signs of trauma and no past medical history.

What do you think happened?

Clues

1. The woman was a bank employee doing normal bank employee things. Unfortunately, when she went into the bank vault, it locked behind her. Whoopsies.
2. She waved at the camera. She banged on the doors. She pulled the fire alarm (but nothing happened?). She tried her phone but had no service and couldn't even tweet. Imagine the horror.
3. She figured she would wait an hour or so until someone else opened the vault… yet, over the course of 30 minutes, the woman slowly dropped to the ground and suffocated to death. What happened? Why did she die so quickly? Let’s learn about asphyxiants!
4. Asphyxiants cause harm by suffocation. There are two categories of asphyxiants– chemical and simple. Chemical asphyxiants (like hydrogen sulfide) interrupt the body's ability to deliver or utilize oxygen.
5. Simple asphyxiants displace the oxygen in the air, making it so there's less oxygen around for you and your body. Thus, when you take a deep breath, you get a mouthful of NOT OXYGEN. Your body/mitochondria are like "ew seriously?"… and then you suffocate.
6. But what does any of this have to do with our case? Well, ask yourself--why is there a fire alarm in a bank vault? Most times when you pull a fire alarm, you trigger a water sprinkler system...but then that would cause the money to get nasty and wet. Gross.
7. So the fire alarm doesn't trigger the release of water. But how else can you put out a fire? By using a CARBON DIOXIDE-BASED FIRE EXTINGUISHER SYSTEM! By releasing carbon dioxide and displacing the oxygen, the combustion reaction cannot occur and fire is put out!

Unfortunately, this woman sealed her fate the moment the fire alarm was pulled. Carbon dioxide filled the bank vault and she suffocated from this simple asphyxiant. Education about the risks with these extinguishers is key– these are preventable deaths.

Simple asphyxiants are everywhere. Virtually every gas (except oxygen) can act as a simple asphyxiant– the dose makes the poison. There are even cases of people dying after being in a room with a bunch of dry ice (sublimation reaction leads to lots of carbon dioxide).

Treatment: Get away from the simple asphyxiant. Get to oxygen. This seems remarkably simple, but unfortunately, can be very challenging in some situations (like when you are trapped in a bank vault).